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California - Lifetime Med - Coverage Terminated
#11
(02-18-2019, 02:28 PM)1171 Wrote:
(02-18-2019, 01:52 PM)spine pain Wrote: [quote='1171' pid='168772' dateline='1548264995']
[quote='spine pain' pid='168768' dateline='1548255319']




My understanding is that if you do not use these lifetime benefits within a set period of time, they automatically will cancel them. Does anyone know where I can verify that? I have applied for SSDI and in that loop now, so that will take a bit of time and fingers crossed, positive on the other side. I have been battling this for years, the docs have told me I should go out. The pain meds have been a big part of enabling that functionality.

Thanks for your help and responses
Your understanding is incorrect. Your court award for future medical treatment is lifetime limited. Refer to your original award documents.

Thanks.. I heard this a while back. I do have the court stipulation for "Lifetime" medical. There is a special place in hell for these guys. If they continued to approved any of the modalities, other than opiods, it would be helpful for the injured worker. They use to cover procedures like clock work, now it has been a total fight and you cannot win. Add to that, the last bit, that enabled functionality, pain meds. I am also reading that spinal cord stimulators are not in favor for workmans comp. I was interested in trying them again, I have had a trial a few years ago, but I didnt go for the implant. The new high frequency ones are supposedly firly decent. Tired of fighting a battle with these guys so I can live somewhat of a life. Anything to screw the injured worker.


Thanks for your help
 
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#12
(02-18-2019, 02:28 PM)1171 Wrote:
(02-18-2019, 01:52 PM)spine pain Wrote: [quote='1171' pid='168772' dateline='1548264995']
[quote='spine pain' pid='168768' dateline='1548255319']




My understanding is that if you do not use these lifetime benefits within a set period of time, they automatically will cancel them. Does anyone know where I can verify that? I have applied for SSDI and in that loop now, so that will take a bit of time and fingers crossed, positive on the other side. I have been battling this for years, the docs have told me I should go out. The pain meds have been a big part of enabling that functionality.

Thanks for your help and responses
Your understanding is incorrect. Your court award for future medical treatment is lifetime limited. Refer to your original award documents.

Thanks.. I heard this a while back. I do have the court stipulation for "Lifetime" medical. There is a special place in hell for these guys. If they continued to approved any of the modalities, other than opiods, it would be helpful for the injured worker. They use to cover procedures like clock work, now it has been a total fight and you cannot win. Add to that, the last bit, that enabled functionality, pain meds. I am also reading that spinal cord stimulators are not in favor for workmans comp. I was interested in trying them again, I have had a trial a few years ago, but I didnt go for the implant. The new high frequency ones are supposedly firly decent. Tired of fighting a battle with these guys so I can live somewhat of a life. Anything to screw the injured worker.


Thanks for your help
 
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#13
Does anyone have any experience on what modalities / medications that will go thru UA/IMR without a hassle for someone with low back post fusion - "failed back surgery syndrome"?
 
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#14
(02-18-2019, 02:28 PM)1171 Wrote:
(02-18-2019, 01:52 PM)spine pain Wrote: [quote='1171' pid='168772' dateline='1548264995']
[quote='spine pain' pid='168768' dateline='1548255319']




My understanding is that if you do not use these lifetime benefits within a set period of time, they automatically will cancel them. Does anyone know where I can verify that? I have applied for SSDI and in that loop now, so that will take a bit of time and fingers crossed, positive on the other side. I have been battling this for years, the docs have told me I should go out. The pain meds have been a big part of enabling that functionality.

Thanks for your help and responses
Your understanding is incorrect. Your court award for future medical treatment is lifetime limited. Refer to your original award documents.

Thanks.. I heard this a while back. I do have the court stipulation for "Lifetime" medical. There is a special place in hell for these guys. If they continued to approved any of the modalities, other than opiods, it would be helpful for the injured worker. They use to cover procedures like clock work, now it has been a total fight and you cannot win. Add to that, the last bit, that enabled functionality, pain meds. I am also reading that spinal cord stimulators are not in favor for workmans comp. I was interested in trying them again, I have had a trial a few years ago, but I didnt go for the implant. The new high frequency ones are supposedly firly decent. Tired of fighting a battle with these guys so I can live somewhat of a life. Anything to screw the injured worker.


Thanks for your help
 
Reply
#15
(01-23-2019, 01:36 PM)1171 Wrote:
(01-23-2019, 10:55 AM)spine pain Wrote: Where to start - California Workman's Comp- settled with lifetime medical in 2000. They initially covered my pain management procedures - then after a few years, it became a nightmare to get covered. They have been covering my medications until this month. Without notice, they stopped covering the opiods that I have been taking for 15 years.


Can they do this without any notice? I am not working and in the process of going on SSDI, due to the issues I am having with my health, related to this injury. I do not know where to tuen on this. I do not live in California anymore, so I do not know where to turn.


Thanks for any advice that can be provided

Treatment approvals and the documentations are handled between the physician & the carrier, generally the patient is not part of that correspondence. I suspect a recent update to the drug formulary was not adequately addressed by your treating physician.
The formularies are here
https://www.dir.ca.gov/dwc/MTUS/MTUS-For...rders.html
You should contact your doctor about getting preapprovals from the carrier for
The highly controlled long time use of opioids. The treatment guidelines do allow for a surpervised plan to reduce patient dependencies on opioids.

I think this is the issue - both of meds are non exempt. Like I mentioned in the other thread, UA has been an absolute nightmare. I called the adjuster and they mentioned that they would gladly settle the lifetime, if I would like. Timing is just really bad.
I have been compliant on the use of the meds and I have even reduced down to the CDC guidelines. My injury is one that I will have pain the rest of my life.
 
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#16
(02-18-2019, 03:09 PM)spine pain Wrote: Does anyone have any experience on what modalities / medications that will go thru UA/IMR without a hassle for someone with low back post fusion - "failed back surgery syndrome"?

I was able to get most requests approved but it took a lot of work and I had to go outside of the guidelines used in work comp if it did not fit my condition or request. I had to do this on my own because most doctors will not spend the time to do this, or get paid for their time.

I don't think your doctors requests will be run through UR if he does not turn them in with a RFA form. If your doctor does not know the guidelines used in CA work comp I can send you a link to the MTUS and chronic pain guidelines, however I do not have a subscription for ODG or ACOEM.

Have you tried a hot cold machine, tens unit and massage?

I know it may be difficult but sometimes weening off of medications (under supervision of a doctor) is good sometimes because then you can see if they were really working. I did not believe this at all when I was on high done opioids because I would get an increase in pain when I reduced the medication. In my case this was temporary.

They have found the brain makes you ultra sensitive to pain when on opioids. It takes time for your brain to recover from long term opioid use and start producing the chemicals such as dopamine. It took me over a year for my body and brain to start to feel normal and I weened myself off very slowly and incorporated walking on a flat surface to increase dopamine production while doing this. What doctors do not always tell their patients is the depression that can come with weening off of opioids as it takes time for your body to produce the natural chemicals in your brain that are associated with happiness. I hope I am explaining this correctly. Exercise can help this.

So like you I have a failed lumbar fusion. My spine is also unstable and I have been told I need another fusion above. I wore a back brace and walked and even tried gentle, modified yoga (under supervision of a doctor) to help. I found the opioids actually were not helping my pain as after a year I felt the same as I did when on the opioids. I understand everyone is different but wanted to mention this to you. What I have found helps me the most is Thai massage (I do not let them walk on my back).I take anti inflammatories, but not all the time and I use lidoderm patches..

This is an article about opioids and what they have found. What I wrote about above I would have never believed until I experienced it myself as I did have an increase in pain when I was weening off. For myself I am glad not to have to be tied down to those medications, worrying about refills, UR and also what long term use does to the brain.

https://www.youtube.com/watch?v=4lv214b7...dD7WtZOwJM
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#17
(02-19-2019, 10:51 AM)California_Help Wrote:
(02-18-2019, 03:09 PM)spine pain Wrote: Does anyone have any experience on what modalities / medications that will go thru UA/IMR without a hassle for someone with low back post fusion - "failed back surgery syndrome"?

I was able to get most requests approved but it took a lot of work and I had to go outside of the guidelines used in work comp if it did not fit my condition or request. I had to do this on my own because most doctors will not spend the time to do this, or get paid for their time.

I don't think your doctors requests will be run through UR if he does not turn them in with a RFA form. If your doctor does not know the guidelines used in CA work comp I can send you a link to the MTUS and chronic pain guidelines, however I do not have a subscription for ODG or ACOEM.

Have you tried a hot cold machine, tens unit and massage?

I know it may be difficult but sometimes weening off of medications (under supervision of a doctor) is good sometimes because then you can see if they were really working. I did not believe this at all when I was on high done opioids because I would get an increase in pain when I reduced the medication. In my case this was temporary.

They have found the brain makes you ultra sensitive to pain when on opioids. It takes time for your brain to recover from long term opioid use and start producing the chemicals such as dopamine. It took me over a year for my body and brain to start to feel normal and I weened myself off very slowly and incorporated walking on a flat surface to increase dopamine production while doing this. What doctors do not always tell their patients is the depression that can come with weening off of opioids as it takes time for your body to produce the natural chemicals in your brain that are associated with happiness. I hope I am explaining this correctly. Exercise can help this.

So like you I have a failed lumbar fusion. My spine is also unstable and I have been told I need another fusion above. I wore a back brace and walked and even tried gentle, modified yoga (under supervision of a doctor) to help. I found the opioids actually were not helping my pain as after a year I felt the same as I did when on the opioids. I understand everyone is different but wanted to mention this to you. What I have found helps me the most is Thai massage (I do not let them walk on my back).I take anti inflammatories, but not all the time and I use lidoderm patches..

This is an article about opioids and what they have found. What I wrote about above I would have never believed until I experienced it myself as I did have an increase in pain when I was weening off. For myself I am glad not to have to be tied down to those medications, worrying about refills, UR and also what long term use does to the brain.

https://www.youtube.com/watch?v=4lv214b7...dD7WtZOwJM

The adjustor is requesting that the Dr place a RFA for the meds. As you and everyone else is aware, all they have to say is no and then the insurance company saves money. I have tapered down from a high dose opioids to where I am now, which is compliant with the CDC guidelines. I have had a ton of back surgery. I have tried the tens units, as well as the spinal cord stimulator, which I did a week trial.
I love the lidoderm patches as well as the compounded lidoderm creme, but they will not approve them and I cannot afford to pay out of pocket at this point anymore.

Thanks for your experienced based input. I would be open to a reduction, if they could provide an alternative to try. My experience has been that they deny everything and hope you go away. My doctor will not fight this, as he doesnt have the bandwidth, as you have experienced. He is also not based in California, so he doesnt have the incentive to learn their process.

Fully agree with the hassle involved, it's a monthly headache. Do you still get any support from your lifetime medical? I am facing another fusion at somepoint as well (ajacent segement disease) from the prior fusion. I am also concerned that they will just drop the lifetime med portion if its not used. 1171 said that they will not, I need to go back and look. I thought I read somewhere that its a use or lose process after x amount of time of none use.


Thanks for your experienced based comments!
 
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#18
I completely closed my medical. However as I wrote above I did get things get authorized by going outside of the guidelines when I was dealing with UR. There came a point where the defense attorney stated they would not run my pain medications through UR anymore as I would successfully appeal them. I was able to get Lidoderm patches approved. I had receptive doctors who would take the info I types up with my history and guidelines and incorporate it in their report, or UR internal appeal or I would do a UR internal appeal. IMR I found was a waste of time as they did not seem to read anything I sent them. This was all a PITA (pain in the ass).


Well if you want my help with trying to get conservative treatments approved like Lidoderm patches I can try to help with looking up guidelines and analyzing your medical conditions to see if you even fit in the limited guidelines. There is no guarantee, but I am willing to help you and see what happens. Your doctor can either incorporate it in his report or you can do a internal UR appeal as long as your UR company does UR internal appeals. If they do the info is located on the last few pages of the UR denial.

You can try calling your claims adjuster (if you are pro per) and having a conversation with her about your situation and if she would allow things like massage and lidoderm patches as a replacement for pain medications. Sometimes claims adjusters have the power to approve things and sometimes they do not.

If you and your doctor decide to ween yourself off of the medications I hope that like me after some time you will feel the same as when you were on the medications. It does take time and does not happen over night. Another thing I experienced while weening myself off was increase insomnia. I took Benadryl at night to help this. I then slowly weened myself off of the Benadryl.
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#19
Has it been 12 months since you received a UR denial for Lidoderm patches?


1171, what is your opinion for California injured workers who are in this situation but have been denied alternative treatments like Lidoderm patches or have reached a cap on things like massage? I know some insurance carriers give claims adjusters power to approve requests while others have everything sent through UR. With the new information about opioids as well as new guidelines they should help these patients who are willing to ween themselves off with help from their doctor. Do you have any recommendations?
I am not an attorney.Anything I write should not be considered legal advice.I am writing from my own personal experiences,which is not from any sort of legal background. You should consult with an attorney over legal issues. In California, if you cannot get an attorney you can consult with an I&A officer.
 
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#20
I’ve been out of touch with day-to-day developments in med treatment policy for awhile so I can only use my historical experience.
The number of variable factors in predicting future treatment allowables/restrictions seems to have grown dramatically as political and financial motivations have overwhelmed the basic structure of the work comp solution to injury liability/responsibility.
IN a word - it’s impossible to predict what rules will be in place 10 or even 5 yrs from now let alone during a“lifetime” award. What “treatment” means for workers comp is no longer stable or dependable.
At this point I Would advise most to attempt to C&R their future care while there s still some value in it-
especially at their 5 yr anniversary point.
Fee schedules, out- of -state docs, drug formularies, set-asides, evidence based treatment standards, etc. and similar add-ons are complications and complexities that are likely to proliferate until we develope a national health care solution.
The comp courts and attys don’t want to deal wih treatment denials. A strong medical opinion by a QME quality California doc with specific information about future treatment needs should lay the ground work for a reasonable medical buyout figure.
I think I answered more then you asked but treatment issues are so varied that I don,t have another single good reply.
Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information. Use the search feature to find information from similar questions.
THANKS FOR POSTING.
 
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